The remed System may be used if you have another stimulation device such as a heart pacemaker or defibrillator; special testing will be needed to ensure the devices are not interacting. Its anatomic location in the neck leaves it vulnerable to traumatic injury. Anatomical and surgical considerations of the phrenic and accessory phrenic nerves. According to a study published in the journal Spinal Cord [1], diaphragm pacing costs about 90% less than the comparable costs for keeping a patient on a positive-pressure ventilator (PPV). Injury to the phrenic nerve can impair the ability of the nervous system to regulate breathing. Less disposable equipment A patient utilizing the Avery Diaphragm Pacing System with a plugged or omitted tracheostoma does not need respiratory tubes, filters, or suction catheters. The remed System delivers a small electrical stimulus to the phrenic nerve while a patient is asleep. The techniques used are derived from the procedures commonly used to treat arm or leg paralysis, which have allowed surgeons to restore function to previously paralyzed muscle groups. Phrenic nerve reconstruction may involve neurolysis, interposition nerve grafting, and/or neurotization, depending on the extent of the injury. Copyright 2022 ZOLL Medical Corporation. Electrodes surgically implanted on the diaphragm are attached to a receiver and an external box with an antenna on the skin's surface. The effect of initial local anesthetic dose with continuous interscalene analgesia on postoperative pain and diaphragmatic function in patients undergoing arthroscopic shoulder surgery: A double-blind, randomized controlled trial. The phrenic nerve controls your diaphragm (the large dome-shaped muscle between your abdominal and chest cavities). Each end of the transected sural nerve is then sewn into a nerve conduit or nerve allograft to promote regeneration and hopefully avoid permanent sequelae of sural nerve sacrifice. To learn more about our services, call 310-825-5510. Phrenic nerve reconstruction may involve neurolysis, interposition nerve grafting, and/or neurotization, depending on the extent of the injury. Make a payment to The Plastic Surgery Center, Make a pagment to The Center for Outpatient Surgery, Inability to perform tasks without feeling winded, A surgical injury, from procedures such as lung surgery, heart valve surgery, aorta surgery, thymus gland surgery, carotid-subclavian bypass surgery, or thoracic outlet syndrome surgery, An anesthetic injury, such as injury from epidural injections or interscalene nerve blocks, Trauma, such as falling from a horse, car accidents, or sports accidents, MRI, if we suspect chronic peripheral nerve compression, Additional diagnostic testing to rule out the possibility of a viral cause or a generalized neurological disorder. After the phrenic nerve is identified, intraoperative nerve threshold testing is used to evaluate any remaining electrical activity prior to intervention. To determine if our revolutionary treatment options can help you, we will begin with a consultation. Hemidiaphragmatic paresis during interscalene brachial plexus block: Effects on pulmonary function and chest wall mechanics. The late August sun can leave a mark. Cervical variations of the phrenic nerve. The diaphragm (white circle) is seen to move caudally, toward the probe, in M-mode. Phrenic nerve function is generally assessed through phrenic nerve conduction studies and fluoroscopic observation of diaphragmatic movement with phrenic nerve stimulation. 105 The nerve then passes from the neck posterior to the subclavian vein to enter the thorax, innervate the ipsilateral diaphragm . Unless the phrenic nerve is injured on both sides, making the patient unable to breathe on his or her own, this is often an elective treatment situation. However, recent advances in medicine have done away with this myth. On a chest X-ray, the diaphragm will appear elevated. Pulmonary function changes after interscalene brachial plexus anesthesia with 0.5% and 0.75% ropivacaine: A double-blinded comparison with 2% mepivacaine. When was your most recent Pulmonary Function Test completed? Effect of unilateral phrenic nerve section on lung function. A new approach for the management of frozen shoulder. Palhais et al.17 recently reported that an ultrasound-guided extrafascial (periplexus) injection of 20 ml bupivacaine 0.5%, performed 4 mm lateral to the brachial plexus sheath not only provided similar analgesia compared with an intraplexus injection between the C5 and C6 roots but also reduced the incidence of diaphragmatic paresis from 90% to 21%. In addition, its system of using small implanted radiofrequency receivers rather than electrode wires that pass directly through the skin may decrease a patients risk of infection and ongoing wound care management issues. (surgery, post-surgical recovery and phrenic conditioning) typically takes 12 weeks. In a clinical study, the remed System has been shown to significantly reduce the effects of CSA: 95% of patient reported they would elect to have the medical procedure again2, 78% of patients reported quality of life improvement using the Patient Global Assessment2, 96% reduction in the median Central Apnea Index at 1 year3, Improvements in sleepdisordered breathingand quality sustainedout to 5 years3, The remed System is approved for adult patients with moderate to severe central sleep apnea. This traditionally has been achieved by performing an interscalene block, which targets the C5 and C6 roots of the brachial plexus in the interscalene region. Complete phrenic nerve palsy may be diagnosed by paradoxical cephalad movement of the diaphragm61,62 or a 75% or greater reduction in diaphragmatic movement.15,41 Diaphragmatic ultrasound has been shown to have high sensitivity (93%) and specificity (100%) in diagnosing phrenic nerve dysfunction.63. Once we determine you are an ideal candidate, we may perform additional diagnostic testing to determine the cause, if possible, and to decide which procedure would be best for you. Phrenic nerve paralysis leads to a poor quality of life, as the person is plagued by chronic fatigue and shortness of breath. Over the first three months of therapy, you will work with your doctor to ensure that the therapy is set up for your individual needs. Rationale: The phrenic nerve stimulation (PNS) is a rare complication after pacemaker setting. The technical storage or access that is used exclusively for statistical purposes. Clin Neurol Neurosurg (2012), doi:10.1016/j.clineuro.2012.01.048. Recovery of diaphragmatic function also was faster in the patients who received the C7 root injection. Update of phrenic nerve injury due to heart ablation. Untreated phrenic nerve paralysis will likely end with the patient being required to use a mechanical ventilator to breathe, and no one likes the thought of that. In the upper image, the phrenic nerve (yellow arrow) can be seen above (superficial to) the ASM in close proximity to the C5 nerve root. Possible causes include injury or a system-wide problem such as diabetes or HIV infection. Some of the procedures are done at West Pavilion building. Diaphragmatic ultrasound. Regardless of the specific type of diaphragm paralysis, the symptoms are generally the same, including: Causes of phrenic nerve injury can vary from accidents and trauma to infections and diseases. This may include one or more of the following: 1) removing scar tissue from around the nerve to allow the electrical signals to travel more easily across the nerve (nerve decompression/neurolysis); 2) cutting out the scar tissue that is filling the nerve gap and bridging it with a sensory nerve (nerve graft); 3) selecting a motor nerve from a healthy but less important muscle group (spinal accessory nerve or intercostal nerves) and transferring it to the injured phrenic nerve (nerve transfer). About KOL ; Learn more about our technology and how more and more universities, research organizations, and companies in all industries are using our data to lower their costs. The Avery Diaphragm Pacing System System is the only diaphragm-pacing system with full pre-market approval from the USFDA and CE marking privileges under the European Active Implantable Medical Device Directive for both adult and pediatric use. Phrenic nerve reconstructionDeveloped by The Institute for Advanced Reconstruction physician Dr. Matthew Kaufman, this procedure is a world-class treatment for phrenic nerve injury to reverse diaphragm paralysis. When were you diagnosed with a paralyzed diaphragm (month/year)? Image adapted with permission from Danilo Jankovic and reproduced with permission from Ultrasound for Regional Anesthesia (USRA; http://www.usra.ca). There are additional risks associated with removing your system. Diaphragmatic reinnervation in ventilator-dependent patients with cervical spinal cord injury and concomitant phrenic nerve lesions using simultaneous nerve transfers and implantable neurostimulators. There is also a lack of studies formally examining clinical predictors of symptomatic phrenic nerve palsy after interscalene block, and thus it remains difficult to determine which patients, healthy or otherwise, will benefit most from avoidance of phrenic nerve palsy. Consequently, there is reduced lung ventilation on the affected side, particularly of the lower lobe.28,30 In healthy individuals, however, tidal volumes remain unchanged due to a greater contribution from the rib cage.11,28 In higher-risk patient groups, hypoxia and dyspnea may ensue and require treatment by sitting the patient upright and administering supplemental oxygen therapy or, in severe cases, instituting noninvasive or invasive ventilatory support to augment tidal volumes. 3 Interscalene brachial plexus block is the most common regional anesthetic technique; however, phrenic nerve palsy and hemidiaphragmatic paresis have traditionally been inevitable consequences, which limit its utility in the . During the hospital stay, pain specialists place the patient on medications that specifically treat nerve pain. Image reproduced with permission from Maria Fernanda Rojas Gomez and Ultrasound for Regional Anesthesia (USRA; http://www.usra.ca). Right and left phrenic nerves to travel between the lung and heart to power each side of the diaphragm. Postoperative diaphragm conditioning therapy can likely lead to diaphragm muscle strengthening that will enhance early surgical improvement and lead to further progress. Make sure your gutters are clean before they start to fill up again this fall. Curved array transducer ultrasound image of the right diaphragm using the liver as an acoustic window in two-dimensional B-mode and M-mode. Reza Jarrahy, MD (left) and Matthew Kaufman, MD (right), Diaphragm Paralysis Caused by Transverse Cervical Artery Compression of the Phrenic Nerve: The Red Cross Syndrome. Ultrasound standard of peripheral nerve block for shoulder arthroscopy: A single-penetration double-injection approach targeting the superior trunk and supraclavicular nerve in the lateral decubitus position. SURGERY for shoulder pathology is increasingly common,1,2 with regional anesthesia playing an important role in multimodal analgesia for these painful procedures.3 Interscalene brachial plexus block is the most common regional anesthetic technique; however, phrenic nerve palsy and hemidiaphragmatic paresis have traditionally been inevitable consequences, which limit its utility in the population of patients at high risk of respiratory complications. This stimulus makes the diaphragm muscle contract, which causes the patient to take a breath . The phrenic nerve often is injured in infants undergoing congenital heart procedures. Suprascapular nerve block prolongs analgesia after nonarthroscopic shoulder surgery but does not improve outcome. On October 6, 2017, the FDA approved the Remede System for adult patients who have been diagnosed with moderate-to-severe CSA. The phrenic nerve provides the primary motor supply to the diaphragm, the major respiratory muscle. That's a savings of up to $20,000 per year. Regional and total lung function studies in patients with hemidiaphragmatic paralysis. Its application to the study of lung function in normal man. Advances in nerve decompression and transplant allow reconstructive plastic surgeons to reverse diaphragm paralysis. Despite this, the vast majority of patients in clinical trials of interscalene block exhibit few symptoms and require no specific treatment.1517 Thus, on the surface, transient phrenic nerve palsy appears to have little clinical significance in terms of both objective (respiratory support) and subjective (dyspnea) features. Phrenic nerve breathing pacemaker surgeryIn this procedure, surgeons implant a breathing pacemaker to control the diaphragm muscle. Ultrasound or fluoroscopy can be used to make the diagnosis of a paralyzed diaphragm. Costanzo MR, Javaheri S, Ponikowski P, et al. Diaphragm pacing. A significant reduction in costs for the long-term care of ventilator-dependent patients is one of the advantages of the Avery Diaphragm Pacing System over a mechanical ventilator. In addition, scar tissue can form in the neck and compress the nerve. After surgery, patients are typically wrapped in a shoulder sling to protect the nerve reconstruction against the motion. So that is one of the paths of the right and left-sided pairs of the phrenic nerve. Unilateral phrenic nerve injury often results in symptomatic hemidiaphragm paralysis. Patient concerns: An 88-year-old man presented himself to the emergency geriatric unit with intermittent painless abdominal contraction due to phrenic nerve stimulation.He has a history of transcatheter aortic valve . If you have been diagnosed with a paralyzed diaphragm, you may be a candidate for phrenic nerve repair. It causes problems with breathing, which is thoroughly uncomfortable on its own. Intraoperative chest fluoroscopy is performed to confirm the diagnosis and assess for immediate results following phrenic nerve reconstruction. The phrenic nerve originates primarily from the fourth cervical ventral ramus but also receives contributions from both third and fifth ventral rami, as well as the cervical sympathetic ganglia or thoracic sympathetic plexus.5 This small nerve forms at the upper lateral border of the anterior scalene muscle and descends obliquely across the anterior surface of the muscle toward its medial border (fig. Long-Term Follow-Up after Phrenic Nerve Reconstruction for Diaphragmatic Paralysis: A Review of 180 Patients. It begins near to the roots of the brachial plexus, then travels inferomedially away from the brachial plexus. However, just as phrenic nerve palsy does not always result in dyspnea, dyspnea may also be experienced in the absence of phrenic nerve palsy.3138 Although up to 40% of patients complain of dyspnea after interscalene block or supraclavicular block,14,17,39 only one third40 to three quarters41 of these patients have objective evidence of phrenic nerve palsy. A randomised controlled trial comparing continuous supraclavicular and interscalene brachial plexus blockade for open rotator cuff surgery. So, while there are risks of further nerve damage, along with all of the risks inherent in any surgery, such as excessive bleeding, reaction to anesthesia, and the like, in these surgeries the rewards far outweigh the potential risks. An injection around the C5C6 nerve roots with volumes of 20 ml or greater inevitably produces phrenic nerve palsy, regardless of localization technique.16,50,51,53 When an ultrasound-guided technique is used, a volume of 10 ml reduces the incidence of phrenic nerve palsy to as low as 60%,52 whereas a volume of 5 ml reduces it still further to between 2758 and 45%,16 without compromising analgesic efficacy up to 24 h postoperatively.16,52 Although McNaught et al.67 determined that the minimum effective volume for achieving analgesia for shoulder surgery with ultrasound-guided interscalene block at the C5C6 nerve root level is as low as 0.9 ml ropivacaine, 0.5%, it must be noted that the duration of analgesia was not assessed formally beyond the first 30 min after surgery. This restriction no longer exists; ultrasound allows visualization of the entire brachial plexus and its individual branches, and thus similar analgesic effects can be achieved with more selective injection further away from the phrenic nerve and the C5 and C6 roots. Neuromuscular ultrasound for evaluation of the diaphragm. The intercostal muscles (ICM) lie superficial to the diaphragm (white circle). The phrenic nerve courses in close proximity to the brachial plexus, initially lying 18 to 20 mm medial to the C5 nerve root at the level of the cricoid cartilage (C5/C6) but diverging an additional 3 mm further away for every centimeter that it descends over the anterior scalene muscle (fig. Lidocaine infusion for continuous interscalene nerve block: Is there evidence for local and systemic benefits? Otherwise, the first step is physical therapy to strengthen the diaphragm, rib, and neck muscles. Elkwood AI, Kaufman MR, Schneider LF, eds. The device is an implantable system which uses stimulation of a nerve in the chest (phrenic nerve) to send signals to the large muscle between the chest and abdomen (the diaphragm). Find a provider Our locations Innovative new surgery repairs phrenic nerve injury, restores breathing function Phrenic nerve function after interscalene block revisited: Now, the long view. 738-742. By 12-18 months, the nerve permanently loses its connection to the muscle. In situations where the diagnosis is unclear, a nerve conduction and muscle study can be ordered to obtain more information on the health of the right and left phrenic nerves and the diaphragm muscle. Surgical treatment of permanent diaphragm paralysis after interscalene nerve block for shoulder surgery. Severe Right Atrial and Ventricular Compression From a Massive Morgagni Hernia and Paralyzed Right Hemidiaphragm, Robotic-Assisted Resection of a Large Solitary Fibrous Tumor Followed by Repair of Iatrogenic Diaphragmatic Hernia, Watch the SCTS 2019 "Take on the Experts" Video Competition, Pulmonary Re-Expansion After Diaphragmatic Plication. The condition is often mis-diagnosed or viewed as insufficiently severe enough to require corrective surgery. Surgery is recommended when it is believed that the chances of achieving further recovery are better with nerve reconstruction than waiting for the nerve to heal on its own. With any surgery there are risks, but the alternative of not having your nerve damage addressed has far more downsides. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. As with any surgically implanted device, there are risks related to the surgical procedure itself which may include, but are not limited to, pain, swelling, and infection. Causes, Symptoms, and Treatment of Phrenic Nerve Damage. Introduction: Phrenic nerve lesion is a known complication of thoracic surgical intervention, but it is rarely described following thymectomy and lung surgery. A 25-gauge needle was inserted through the skin wheal and advanced underneath . The superior trunk also can be targeted at the supraclavicular brachial plexus level. The optimal regional anesthetic approach in shoulder surgery should be tailored to individual patients based on comorbidities, type of surgery, and the principles described in this article. This video demonstrates surgical repair of the phrenic nerve in a patient diagnosed with right diaphragm paralysis resulting from a prior neck surgery. 5). These signals stimulate breathing in the same way that the brain signals breathing. The Institute for Advanced Reconstruction is one of the only places worldwide that performs diaphragm pacemaker implantation in select patients with unilateral or bilateral diaphragm paralysis due to phrenic nerve injury. These include the intercostal nerves, 4,5 the spinal accessory nerve, 2 and the motor branches of the cervical plexus. Although there is an initial cost outlay for the surgical implants of the Avery Diaphragm Pacing System, the system can pay for itself in less than a year. If rib (intercostal) nerves are used as nerve transfers, patients may be admitted overnight in the Intensive Care Unit as a precaution to monitor their breathing and then stay for 3-4 days before being discharged to home. Activities the person formerly enjoyed are basically out of the question due to inherent difficulty with simple breathing. March 2019. doi:10.25373/ctsnet.7863332. Furthermore, one anatomical study indicate, that the phrenic nerve on the right side supply the liver capsule with thin sensory nerves. They were often told by their physicians that they would simply have to live with it. Phrenic nerve palsy is considered a relatively minor cause of the frequent postoperative pulmonary complications that occur with cardiac surgery; approximately 10% or less of open-heart surgical cases have apparent phrenic nerve dysfunction. Anterior (left) and posterior (right) innervation of the shoulder. Asymptomatic profound oxyhemoglobin desaturation following interscalene block in a geriatric patient. Learn More Share With Friends Request Information Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction. Phrenic Nerve Paralysis may occur during birth, following trauma, or from radiation, tumor, or a virus. Neuropathy is damage to or dysfunction of a nerve or group of nerves. Eric Vallieres. According to a study published in the journal Spinal Cord [1], diaphragm pacing costs about 90% less than the comparable costs for keeping a patient on a positive-pressure ventilator (PPV). 212-305-7950. MT = middle trunk; ST = superior trunk. 6 years ago 21 Replies. The clinical aim of regional anesthesia or analgesia is to deliver local anesthetic to some or all of these key nerves that contribute to pain after shoulder surgery. If nerve damage is left for over a year, there is a good chance the nerve will permanently lose its connection to the diaphragm. The remed System reduces the number of sleep apnea events at night and daytime sleepiness and improves sleep quality and quality of life, as assessed by patients.3. If you and your doctor decide to remove the system, another surgery will be required. The phrenic nerve controls function of the diaphragm muscle; the primary muscle involved in breathing. Did you have surgery or trauma that caused damage to your phrenic nerve? An overview of unilateral and bilateral diaphragmatic paralysis and nonsurgical treatments is reviewed separately. Now, Dr. Kaufman and his team have found a way to offer it to both children and adults who experience diaphragm paralysis. Or, a doctor might prescribe tricyclic antidepressants[, In severe cases, nerve decompression surgery such as carpal tunnel release[, Many hospitals, doctors and physical therapists give discounts of up to 30% or more to uninsured/cash-paying patients. After closing the incisions and applying the dressings, the patient is partially reversed from anesthesia to the point at which they are breathing spontaneously, so that a postoperative fluoroscopic evaluation may be performed. These signals stimulate breathing in the same way that the brain signals breathing. Are you interested in learning more about phrenic nerve damage treatment and diaphragm paralysis? The double crush in nerve entrapment syndromes. If a hospital admission or two is avoided (from ventilator-induced pneumonia, for example), the diaphragm pacing system can pay for itself in even less time. From our vast experience in evaluating thousands, and treating hundreds of patients over the last fifteen years, we have clearly identified that most cases of Idiopathic Diaphragm Paralysis are actually a result of chronic peripheral nerve compression in the neck region. In addition, other operating costs associated with mechanical ventilation are either reduced substantially or eliminated altogether. Telehealth Services. When this occurs, we refer to the condition as Idiopathic Diaphragm Paralysis. 6) in a two-dimensional B-mode. Pruning trees before the storm season can help ensure dead branches won't imperil your home. Refining the ultrasound-guided interscalene brachial plexus block: The superior trunk approach. By. Successful continuous interscalene analgesia for ambulatory shoulder surgery in a private practice setting. (A) Preblock sniff test assessment for phrenic nerve palsy. They noted that none of the 20 patients who received 6 ml ropivacaine 0.75%, or less had any evidence of diaphragmatic paresis up to 2 h after injection.57. The shoulder block: A new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain. For additional information on Phrenic Nerve Paralysis and Paralyzed Diaphragm treatment in Los Angeles, CA, call our office at (310) 423-2129 to schedule a consultation today! With this device, electrodes are placed on the phrenic nerve in the neck or chest and connect to an external device that creates radio waves. The C5C7 roots of the brachial plexus emerge deep to the ASM, coursing laterally, where C5 and C6 roots merge to form the superior trunk. Cervical spine disease is a risk factor for persistent phrenic nerve paresis following interscalene nerve block. Home Conditions Trunk Phrenic Nerve Paralysis Treatment in Los Angeles, CA. Surgical treatment focuses on healing the injured nerve(s). Incidence of phrenic nerve block after interscalene brachial plexus block. Phrenic nerve surgery is performed under general anesthesia and can last a few hours. See a direct comparison between the Avery Diaphragm Pacemaker and the leading competitors diaphragm pacing system. This shows that the therapy is active. SURGERY for shoulder pathology is increasingly common, 1,2 with regional anesthesia playing an important role in multimodal analgesia for these painful procedures. The specific nerves to be targeted will depend in part on the surgical approach that is used (fig. Many patients with phrenic nerve injuries have been told that they must simply learn to live with this deficit. All Rights Reserved. In: Friedberg JS, Collins KA, eds. Another approach is to use a short-acting agent such as lidocaine instead of ropivacaine or bupivacaine. It's essential to breathing. Bony and capsular components are innervated by the suprascapular, axillary, lateral pectoral (C5C7), musculocutaneous (C5C7), and long thoracic (C5C7) nerves (fig. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you. In men, the normal displacement of an unaffected diaphragm is 1.8 0.3, 7.0 0.6, and 2.9 0.6 cm in quiet breathing, deep breathing, and sniffing, respectively, and 1.6 0.3, 5.7 1.0, and 2.6 0.5 cm in women.60 Once again, it is ideal to obtain baseline measures of diaphragmatic excursion before block performance. It is small and unobtrusive. Diaphragmatic motion studied by m-mode ultrasonography: Methods, reproducibility, and normal values. Patients usually stay awake, but are drowsy during the procedure. There are no studies reporting the impact of injection dynamics on phrenic nerve palsy. The fibers of the accessory phrenic nerve arise primarily from C5 and run within the nerve to subclavius, the ansa cervicalis, or the nerve to sternohyoid.7 These fibers then emerge from any one of these nerves to form the accessory phrenic nerve, which then joins the phrenic nerve at a variable location along its course.8,9 Isolated damage to the accessory phrenic nerve is associated with diaphragmatic dysfunction,10 and similarly, reports suggest that local anesthetic blockade of the accessory nerve also may lead to diaphragmatic paresis.11,12, Phrenic nerve palsy leading to hemidiaphragmatic paresis may be a temporary or persistent phenomenon after interscalene block or other injections of local anesthetic in the neck. The sural nerve is then sewn into the phrenic nerve, proximal and distal to the visualized defect. Most patients adjust to the therapy within the first 3 months. Objective: To review the literature on thoracic intervention and phrenic nerve lesion and to describe four new cases, in which regular neurophysiological studies were performed. Early results are comparable to sternotomy and VATS approaches. Anesthesiology 2017; 127:173191 doi: https://doi.org/10.1097/ALN.0000000000001668. PZiglar01 . Surgery to the neck, chest, or liver can damage the nerve, and cardiac surgery is the most common cause of trauma to the phrenic nerve. The remed system is indicated for moderate to severe Central Sleep Apnea in adult patients. To learn more about our services, call 310-825-5510. Theremed System should not be placed if an active infection is present. Phrenic nerve injury that results in diaphragm paralysis can significantly decrease quality of life. The diaphragm is the main breathing muscle and contraction of the diaphragm is vital for ventilation so any disease that interferes with diaphragmatic innervation, contractile muscle function, or mechanical coupling to the chest wall can cause diaphragm dysfunction.
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